Management and Evaluation of Care for Acutely and Critically Ill Infants, Children, and Adolescents
Management is a loop, not a checklist
Every intervention is followed by reassessment. Fluid resuscitation is 10–20 mL/kg of isotonic crystalloid given as a rapid bolus in most forms of shock, with a full reassessment between boluses; cardiogenic and obstructive shock require smaller volumes and early vasoactive or decompressive intervention. Blood products, not crystalloid, are the definitive therapy for hemorrhagic shock. Respiratory support escalates deliberately: low-flow oxygen, high-flow nasal cannula, noninvasive ventilation, then intubation with attention to the child most likely to decompensate during induction.
High-yield management sets
- Status asthmaticus: albuterol, ipratropium, early systemic corticosteroids, magnesium sulfate, and escalating support; watch for a silent chest.
- Diabetic ketoacidosis: isotonic fluid, insulin infusion, no bicarbonate, and hourly neurologic checks. Headache, bradycardia with hypertension, or a falling mental status signals cerebral edema - stop the insulin, elevate the head, and treat with hypertonic saline or mannitol.
- Raised intracranial pressure: midline head, avoid hypoxia and hypotension, controlled ventilation, and serial neuro exams.
- Sedation, analgesia, nutrition, and device care are active management, not afterthoughts; unmanaged pain and underfeeding worsen outcomes.
Traps
Giving repeated boluses without reassessing in cardiac or renal disease; treating fever before obtaining cultures in suspected sepsis; ordering panels of labs with no question attached; assuming a normalized number equals a stabilized patient; and delaying escalation because the child "looks okay right now."
Worked example
A 5-year-old in DKA arrives tachycardic and drowsy. Give 10 mL/kg isotonic bolus, start maintenance isotonic fluid, begin insulin infusion, and check neuro status and glucose hourly. Two hours later the child reports a new headache with bradycardia and rising blood pressure - this is cerebral edema until disproven. Pause the insulin, give hypertonic saline, elevate the head of the bed, and escalate.